Advances in surgery
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Nonoperative treatment is best for hemodynamically stable patients with blunt liver injuries and in selected patients with penetrating injuries. However, most patients with penetrating injuries require early surgical intervention to control life-threatening hemorrhage or manage associated injuries. ⋯ In patients with persistent hemorrhage that cannot be controlled by surgical means, immediate transfer to the angiography suite for selective embolization may be a lifesaving alternative. Surgeons should not hesitate to operate on a patient for complications, but many of these can be managed by delayed, less-invasive procedures such as angiography, CT-guided drainage of collections, laparoscopy, or endoscopic retrograde cholangiopancreatography.
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In spite of the limited direct evidence available, increasing data support a positive volume-outcome association in trauma care. When coupled with the extensive indirect data suggesting that regions with organized systems of trauma care are associated with lower trauma-related mortality rates than regions where the number of centers and their level of commitment are unlimited and untested, there is little doubt that experience improves outcome and that volume plays a critical role in the accrual of experience. ⋯ Several reports have suggested that trauma outcomes in smaller rural level 3 centers or centers with dedicated trauma programs with appropriate, functional triage protocols are comparable to national norms, thus reflecting the importance of commitment to outcome. These data suggest that quality of care does not only follow volume, particularly when stipulations and requirements are clear regarding the process of care and ongoing quality assurance.